E. Schokkaert (Schokkaert)http://repub.eur.nl/ppl/14302/
List of Publicationsenhttp://repub.eur.nl/eur_signature.pnghttp://repub.eur.nl/
RePub, Erasmus University RepositoryInequity in the face of deathhttp://repub.eur.nl/pub/76651/
Fri, 01 Aug 2014 00:00:01 GMT<div>M.P. García-Gómez</div><div>E. Schokkaert</div><div>T.G.M. van Ourti</div><div>T.M. Bago d'Uva</div>
We apply the theory of inequality of opportunity to the measurement of inequity in mortality. Using a rich data set linking records of mortality and health events to survey data on lifestyles for the Netherlands (1998-2007), we test the sensitivity of estimated inequity to different normative choices and conclude that the location of the responsibility cut is of vital importance. Traditional measures of inequity (such as socioeconomic and regional inequalities) only capture part of more comprehensive notions of unfairness. We show that distinguishing between different routes via which variables might be associated to mortality is essential to the application of different normative positions. Using the fairness gap (direct unfairness), measured inequity according to our implementation of the 'control' and 'preference' approaches ranges between 0.0229 and 0.0239 (0.0102-0.0218), while regional and socioeconomic inequalities are smaller than 0.0020 (0.0001). The usual practice of standardizing for age and gender has large effects on measured inequity. Finally, we use our model to measure inequity in simulated counterfactual situations. While it is a big challenge to identify all causal relationships involved in this empirical context, this does not affect our main conclusions regarding the importance of normative choices in the measurement of inequity.Preconditions for efficiency and affordability in competitive healthcare markets: Are they fulfilled in Belgium, Germany, Israel, the Netherlands and Switzerland?http://repub.eur.nl/pub/40016/
Fri, 01 Mar 2013 00:00:01 GMT<div>W.P.M.M. van de Ven</div><div>K. Beck</div><div>F. Buchner</div><div>E. Schokkaert</div><div>F.T. Schut</div><div>A. Shmueli</div><div>J. Wasem</div>
Context: From the mid-1990s several countries have introduced elements of regulated competition in healthcare. The aim of this paper is to identify the most important preconditions for achieving efficiency and affordability under regulated competition in healthcare, and to indicate to what extent these preconditions are fulfilled in Belgium, Germany, Israel, the Netherlands and Switzerland. These experiences can be worthwhile for other countries (considering) implementing regulated competition (e.g. Australia, Czech Republic, Ireland, Russia, Slovakia, US). Methods: We identify and discuss ten preconditions derived from the theoretical model of regulated competition and assess the extent to which each of these preconditions is fulfilled in Belgium, Germany, Israel, the Netherlands and Switzerland. Findings: After more than a decade of healthcare reforms in none of these countries all preconditions are completely fulfilled. The following preconditions are least fulfilled: consumer information and transparency, contestable markets, freedom to contract and integrate, and competition regulation. The extent to which the preconditions are fulfilled differs substantially across the five countries. Despite substantial progress in the last years in improving the risk equalization systems, insurers are still confronted with substantial incentives for risk selection, in particular in Israel and Switzerland. Imperfect risk adjustment implies that governments are faced with a complex tradeoff between efficiency, affordability and selection. Conclusions: Implementing regulated competition in healthcare is complex, given the preconditions that have to be fulfilled. Moreover, since not all preconditions can be fulfilled simultaneously, tradeoffs have to be made with implications for the levels of efficiency and affordability that can be achieved. Therefore the optimal set of preconditions is not only an empirical question but ultimately also a matter of societal preferences. Reference value sensitivity of measures of unfair health inequalityhttp://repub.eur.nl/pub/76255/
Tue, 01 Jan 2013 00:00:01 GMT<div>M.P. García-Gómez</div><div>E. Schokkaert</div><div>T.G.M. van Ourti</div>
Most politicians and ethical observers are not interested in pure health inequalities, as they want to distinguish between different causes of health differences. Measures of "unfair" inequality - direct unfairness and the fairness gap, but also the popular standardized concentration index (CI) - therefore neutralize the effects of what are considered to be "legitimate" causes of inequality. This neutralization is performed by putting a subset of the explanatory variables at reference values, for example, their means. We analyze how the inequality ranking of different policies depends on the specific choice of reference values. We show with mortality data from the Netherlands that the problem is empirically relevant and we suggest a statistical method for fixing the reference values. CopyrightSupplemental health insurance and equality of access in Belgiumhttp://repub.eur.nl/pub/37510/
Thu, 01 Apr 2010 00:00:01 GMT<div>E. Schokkaert</div><div>T.G.M. van Ourti</div><div>D. de Graeve</div><div>A. Lecluyse</div><div>C. van de Voorde</div>
The effects of supplemental health insurance on health-care consumption crucially depend on specific institutional features of the health-care system. We analyse the situation in Belgium, a country with a very broad coverage in compulsory social health insurance and where supplemental insurance mainly refers to extra-billing in hospitals. Within this institutional background, we find only weak evidence of adverse selection in the coverage of supplemental health insurance. We find much stronger effects of socio-economic background. We estimate a bivariate probit model and cannot reject the assumption of exogeneity of insurance availability for the explanation of health-care use. A count model for hospital care shows that supplemental insurance has no significant effect on the number of spells, but a negative effect on the number of nights per spell. We comment on the implications of our findings for equality of access to health care in Belgium. Copyright Hospital supplements in Belgium: Price variation and regulationhttp://repub.eur.nl/pub/16988/
Thu, 01 Oct 2009 00:00:01 GMT<div>A. Lecluyse</div><div>C. van de Voorde</div><div>D. de Graeve</div><div>E. Schokkaert</div><div>T.G.M. van Ourti</div>
Objectives: Although there is a comprehensive public health insurance system in Belgium, out-of-pocket expenditures can be very high, mainly for inpatients. While a large part of the official price is reimbursed, patients are confronted with increased extra billing (supplements). Therefore, the government imposed various restrictions on the amount of supplements to be charged, related to the type of room and the patient's insurance status. We investigate how prices are set and whether the restrictions have been effective. Methods: We use an administrative dataset of the Belgian sickness funds for the year 2003 with billing data per hospitalisation and hospital characteristics. Boxplots describe the distribution of several categories of supplements. OLS is used to explore the relationship between hospital characteristics and extra billing. Results: There is a large and intransparent variation in extra billing practices among different hospitals. Given the room type, supplements per day are smaller for patients qualifying for protection, confirming that the regulation is applied quite well. However, because of their longer length of stay this does not result in lower supplements per stay for these patients. Conclusions: Currently the price setting behavior of providers lacks transparency. Protective regulation could be refined by taking into account the longer length of stay of vulnerable groups.Wie betaalt supplementen in de Belgische gezondheidszorg?http://repub.eur.nl/pub/37570/
Mon, 01 Jan 2007 00:00:01 GMT<div>D. de Graeve</div><div>A. Lecluyse</div><div>E. Schokkaert</div><div>T.G.M. van Ourti</div><div>C. van de Voorde</div>
Ondanks de genomen beschermingsmaatregelen (bv. de maximumfactuur) zijn de eigen betalingen voor gezondheidszorg van de patiënten gedurende de laatste jaren gestegen. Deze eigen betalingen bestaan uit remgelden en supplementen. In dit artikel onderzoeken we de sociale gevolgen van deze evolutie: we analyseren de omvang van de supplementen en vooral ook hun verdeling over de Belgische bevolking. De analyses gebeuren op basis van de administratieve gegevens van de terugbetalingen binnen de verplichte ziekteverzekering in 2003 voor een steekproef van 300.000 individuen.
We vinden datMaximumfactuur en kleine risico’s: verdeling van de eigen bijdragen voor gezondheidszorg in Belgiëhttp://repub.eur.nl/pub/37571/
Thu, 01 Jan 2004 00:00:01 GMT<div>E. Schokkaert</div><div>D. de Graeve</div><div>G. Camp</div><div>T.G.M. van Ourti</div><div>C. van de Voorde</div>
Overal in Europa komt de financiering van publieke systemen van ziekteverzekering of gezondheidszorg onder druk door de sterke stijging van de uitgaven. België ontsnapt niet aan deze evolutie. De stijging van de uitgaven voor gezondheidszorg lag bij ons zeker gedurende de laatste jaren zelfs duidelijk boven het Europese gemiddelde. Ondanks de grote maatschappelijke populariteit van ons systeem van verplichte ziekteverzekering, vormt het probleem van de kostenbeheersing toch steeds één van de belangrijkste discussiepunten tijdens de regeringsonderhandelingen. Wanneer de stijging van de uitgaven niet kan worden afgeremd, zullen in de toekomst ongetwijfeld fundamentele vragen over de organisatie van het systeem naar voor worden geschoven (Schokkaert en Van de Voorde, 2003).Risk adjustment and risk selection on the sickness fund insurance market in five European countrieshttp://repub.eur.nl/pub/67068/
Tue, 01 Jul 2003 00:00:01 GMT<div>W.P.M.M. van de Ven</div><div>K. Beck</div><div>F. Buchner</div><div>D. Chernichovsky</div><div>L. Gardiol</div><div>J.M.P. Holly</div><div>L.M. Lamers</div><div>E. Schokkaert</div><div>A. Shmueli</div><div>S. Spycher</div><div>C. van de Voorde</div><div>R.C.J.A. van Vliet</div><div>J. Wasem</div><div>I. Zmora</div>
From the mid-1990s citizens in Belgium, Germany, Israel, the Netherlands and Switzerland have a guaranteed periodic choice among risk-bearing sickness funds, who are responsible for purchasing their care or providing them with medical care. The rationale of this arrangement is to stimulate the sickness funds to improve efficiency in health care production and to respond to consumers' preferences. To achieve solidarity, all five countries have implemented a system of risk-adjusted premium subsidies (or risk equalization across risk groups), along with strict regulation of the consumers' direct premium contribution to their sickness fund. In this article we present a conceptual framework for understanding risk adjustment and comparing the systems in the five countries. We conclude that in the case of imperfect risk adjustment - as is the case in all five countries in the year 2001 - the sickness funds have financial incentives for risk selection, which may threaten solidarity, efficiency, quality of care and consumer satisfaction. We expect that without substantial improvements in the risk adjustment formulae, risk selection will increase in all five countries. The issue is particularly serious in Germany and Switzerland. We strongly recommend therefore that policy makers in the five countries give top priority to the improvement of the system of risk adjustment. That would enhance solidarity, cost-control, efficiency and client satisfaction in a system of competing, risk-bearing sickness funds.Effects of cost sharing on physician utilization under favourable conditions for supplier-induced demandhttp://repub.eur.nl/pub/11384/
Wed, 29 Aug 2001 00:00:01 GMT<div>C. van de Voorde</div><div>E.K.A. van Doorslaer</div><div>E. Schokkaert</div>
The effects of cost sharing on the demand for ambulatory care in experimental circumstances are well understood since the Rand Health Insurance Experiment (HIE). However, in a non-experimental real-world context, supplier-induced demand of doctors might erode some of the significant negative out-of-pocket price elasticity identified in the HIE. Belgium is an interesting test case for this hypothesis because it has relatively high rates of patient cost sharing in its public health insurance system and a very high density of physicians, all remunerated fee-for-service. We have exploited the price variation generated by a substantial increase in patient co-payment rates in 1994 to estimate out-of-pocket price elasticities for three groups of users, and for three types of services using a fixed-effects model in levels and in differences. We obtain significant out-of-pocket price elasticities for the general population in the range from -0.39 to -0.28 for GP home visits, -0.16 to -0.12 for GP office visits and -0.10 for specialist visits. The estimates were generally lower and less significant for the groups of elderly and disabled. The differences we find in price responsiveness appear to be fairly robust and consistent with the HIE predictions. These results suggest that - at least in the short run - non-experimental utilization effects of cost sharing are very similar to the experimental evidence, even in a situation of favourable conditions for supplier-induced demand.